HospitalInspections.org
Bringing transparency to federal inspections
CORPUS CHRISTI MEDICAL CENTER,THE
CONTENT OF RECORD: ORDERS,NOTES,REPORTS
Tag No.: A0467
Based on review of a medical record of a 15-year-old male patient, 17-year-old female patient, and interview of staff. This requirement is not met as follows:
Findings:
a. In review of medical record of (patient #1) MRN # DO00846461, a 15-year-old male patient who was admitted to the facility for Major Depressive Disorder, Severe Psychotic features, and Suicidal plans that on 11/29/2018 at 3:35pm doctors order number 20181129-1310 was written for the (patient #a) to be 1:1 supervision/observation for safety reasons. Additionally, on 11/29/2018 at 6:10pm it was documented by the (assigned nurse #1), that (patient#1) was discontinued from 1:1 for safety/observation reasons. There were no doctors' orders documented in the record to support the nurses note.
In review of medical record for (patient #2) MRN # DO0084711, a 17-year-old female who was emergency detained for anxiety/depression, suicidal ideations. On 12/1/2018 (patient #2) alleged that (patient #1) touched her leg, hair and breast. Camera footage from date 12/1/2018 between 5:00pm and 8:00pm revealed that (patient #1) had touched (patient #2's) leg and hair but could not see where (patient #1) touched her breast. There was no 1:1 staff present with (patient #1) in the video footage.
b. On April 10, 2019 at 2:30pm in the facility conference room (Nurse # 1), was interviewed and reviewed the medical record for documentation in the record. She explained that the verbal order was given to her but she neglected to complete the order in the computer system.
c. In review of the Texas Nurse Practice Act 217.11 Standards of Nursing Practice, it states in part:
"(1) Standards Applicable to all Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: ...
(D) Accurately and completely report and document:
(i) the client's status including signs and symptoms;
(ii) nursing care rendered; ...
(v) client responses; and
(vi) contacts with other health care team members concerning significant events regarding clients status"